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Your Clinic Name

Dr. Name | Reg: Number

Phone Email Website

Initial Assessment

Patient Name:

Date:

Age / Sex:

Contact No:

Ref. Dr:

1. Chief Complaints & History

2. On Examination (O/E)

Posture, ROM, Muscle Power, Special Tests, Neurological

Pain Scale (VAS 0-10)

0 (No Pain)

10 (Worst)

Provisional Diagnosis

3. Treatment Plan & Modalities

IFT

TENS

Ultrasound (US)

SWD / MWD

Traction

Muscle Stimulator

Laser Therapy

Hot/Cold Pack

Dry Needling

Exercise Therapy

Manual Therapy

Taping

Other Details:

Patient Name: _______________________ | ID/Ref: ___________

30-Day Treatment Record

Day	Date	VAS	Treatment / Modalities / Exercises Given	Patient Sign